EM · Procedural & diagnostic ED skills
Point-of-care ultrasound: aortic, lung and cardiac (the RUSH protocol)
Also known as POCUS · Point-of-care ultrasound · Bedside ultrasound · RUSH protocol · Rapid Ultrasound in Shock · Lung ultrasound · Focused cardiac ultrasound
Bedside point-of-care ultrasound of the aorta, the lung and the heart for the critically ill patient — the aortic measurement (the abdominal aortic aneurysm is an outer-to-outer aortic diameter over 3 cm), the lung patterns (the B-lines for pulmonary oedema, the A-lines for the normal lung or COPD, the absent lung sliding and the lung point for pneumothorax), the cardiac windows (the pericardial effusion, the eyeball left-ventricular function, the right-ventricular dilatation of pulmonary embolism) and the inferior-vena-cava collapsibility for the volume status. Integrated by the RUSH protocol (Rapid Ultrasound in Shock), which maps the pump, the tank and the pipes to answer the shock question at the bedside. ACEM-primary, globally tagged.
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Related topics
- Focused Assessment with Sonography in Trauma (FAST and E-FAST)
- Abdominal aortic aneurysm (ruptured and intact)
- Pneumothorax (including tension pneumothorax)
- Pulmonary embolism (acute, in the emergency department)
- Pericardial tamponade
- Acute decompensated heart failure and cardiogenic pulmonary oedema
- Acute exacerbation of chronic obstructive pulmonary disease
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Target exams
Red flags
- An aortic diameter over 3 cm measured outer-to-outer is an abdominal aortic aneurysm — measure at the widest point, and a retroperitoneal fluid stripe beside an aneurysm in the shocked patient is rupture until proven otherwise
- A-lines are normal — but A-lines plus absent lung sliding is pneumothorax, and A-lines plus bilateral B-line-free lungs in respiratory failure points to pulmonary embolism, not heart failure
- The lung point is the only sonographic sign near-diagnostic of pneumothorax — its absence never excludes one, its presence confirms it
- A pericardial effusion with right-ventricular free-wall collapse in diastole is tamponade — a clinical diagnosis the scan confirms, never a scan diagnosis alone
- A dilated hypokinetic right ventricle with a septal bowing into the left ventricle is massive pulmonary embolism — the McConnell sign is regional, sparing the apex
Meet the patient
A 76-year-old smoker is wheeled into resus grey, sweaty and drowsy, BP 82/50, HR 124, after tearing abdominal and back pain and a syncopal episode at home. Your hand is already on the curvilinear probe before the cannula is in.[1]
Now hold the other picture next to it: a 68-year-old woman two weeks after a knee replacement, suddenly breathless and presyncopal, BP 78/52, JVP to the jaw, and clear lung fields. The probe in her subxiphoid view shows a dilated, hypokinetic right ventricle. Same machine, same protocol — and two completely different resuscitations. The RUSH exam is the skill that turns "shocked, cause unknown" into "ruptured AAA, call theatre" or "massive PE, give the lysis" before the bloods are back.[1]
References11ShowHide
- [1]Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am, 2010.PMID 19945597
- [2]Volpicelli G, Elbarbary M, Blaivas M, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med, 2012.PMID 22392031
- [3]Lichtenstein DA, Mezière GA, Lagoueyte JF, Biderman P, Goldstein I, Gepner A. A-lines and B-lines: lung ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill. Chest, 2009.PMID 19809049
- [4]Lichtenstein D, Mezière G, Biderman P, Gepner A. The lung point: an ultrasound sign specific to pneumothorax. Intensive Care Med, 2000.PMID 11126253
- [5]Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest, 2008.PMID 18403664
- [6]Ashton HA, Buxton MJ, Day NE, et al. The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet, 2002.PMID 12443589
- [7]McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol, 1996.PMID 8752195
- [8]Mandavia DP, Hoffner RJ, Mahaney K, Henderson SO. Bedside echocardiography by emergency physicians. Ann Emerg Med, 2001.PMID 11574793
- [9]Orso D, Paoli I, Piani T, et al. Accuracy of Ultrasonographic Measurements of Inferior Vena Cava to Determine Fluid Responsiveness: A Systematic Review and Meta-Analysis. J Intensive Care Med, 2020.PMID 29343170
- [10]Shuman WP, Hastrup W Jr, Kohler TR, et al. Suspected leaking abdominal aortic aneurysm: use of sonography in the emergency room. Radiology, 1988.PMID 3289085
- [11]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet, 2010.PMID 20554319